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Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI: 20 y/o otherwise healthy male presents to the ED with a rash on his neck. He states he woke up with the rash. It burns, but is not pruritic. He’s never had it before. He endorses some chills, but no fevers. He states these lesions all appeared in areas where he had been shaved yesterday at the Barber Shop.

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Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI: 20 year old female with no significant past medical history who presents to the ED with one week of severe, diffuse abdominal pain. She’s never had this pain before. It waxes and wanes. Nothing makes it better or worse. It is associated with nausea, intermittent joint pain and swelling, and a non-pruritic rash on her lower extremities. She states she had a head cold about three weeks ago, but has been otherwise well. She denies fevers, chills, headache, shortness of breath, chest pain, nausea, vomiting, diarrhea, or urinary symptoms. Of note, she was seen at an urgent care when her symptoms started and put on doxycycline for presumed Lyme, although she denies any tick bites.

Vitals: BP 126/81, HR 73, T 98.7 °F, RR 18, SpO2 100 % on RA

Notable physical exam findings: Mild, diffuse abdominal tenderness, but no rebound or guarding. She has scattered, raised, purpuric lesions on her bilateral lower extremities. They are non-painful and non-blanchable (see below).

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A 15 y/o male with a history of diabetes mellitus and hypothyroidism presents to the ED with a diffuse rash. It is not painful or pruritic. Of note, he was seen at the at his primary care doctors office earlier that week and found to have hyperglycemia (400’s) and hypertriglyceridemia (>10,000 mg/dL):

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Two cases this week! Thank you to Dr. David Kaplan for submitting the first case, while the second case was one seen by myself and Dr. Paul Cheung.

Case 1:

58 y/o male sustained blunt force trauma to the lateral aspect of his right knee. On exam, there is a mild right knee effusion, but no obvious deformities. Pain with ROM. Neurovascularly intact. No ligamentous laxity appreciated. X-rays of the right knee are obtained:

Case 2:

22 y/o male sustained a gunshot wound to the right knee. On exam, there is an entrance wound on the posterior-lateral aspect of the knee, but no exit wound. There is pain with ROM of the knee and a mild effusion is appreciated. No obvious deformities. Neurovasculary intact. No ligamentous laxity appreciated. Initial plain films demonstrate the bullet lodged in the mid-thigh. Physical exam findings and x-rays of the right knee:

Given concern for an open joint, an aspiration is performed prior to irrigation, and the following aspirate is obtained:

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This is a case I saw in the ED. This case has been deliberately altered to protect the identity of the patient:

28 y/o patient presents to the ED after sustaining blunt trauma to the chest. An EKG is ordered as part of her workup:

Upon further questioning, the patient endorses periods of palpitations over the past couple of months where her “heart was racing”. She denies chest pain, shortness of breath, dizziness, or syncope with these episodes. What’s the diagnosis?